UNIT 15.

2 Destructive Operations (Embryotomy)

Definition
Destructive operations are a group of operations aims at reducing the size of the head, shoulder
girdle or trunk of the dead unborn fetus to allow its easy vaginal delivery. These procedures were
adopted in the past to deliver the dead fetus when a mother suffering from an obstructed labour
and threatened uterine rupture. These operations are performed rarely in places where the facility
of caesarean section is not available or when the fetus is already dead.
Types of destructive operations
1. Craniotomy craniocentesis
2. Decapitation
3. Cleidotomy
4. Evisceration
5. Spondylotomy
Contraindications

Living foetus except in certain congenital anomalies incompatible with life as

anencephaly which may be associated with large shoulder girdle. However, destruction of
a living foetus for whatever the cause may not be accepted from the religious point of
view.

Extreme degree of contracted pelvis i.e. true conjugate < 5.5 cm.

Partially dilated cervix.

Rupture or impending rupture uterus.

Obstructing pelvic tumours.

Cancer of the cervix with pregnancy.

Complications

Uterine rupture.

Injuries to the genital tract.

1. CRANIOTOMY
Definitions

Craniotomy: perforation of the foetal head (cranium).

Cranioclasm: crushing of the cranium.

Cephalotripsy: crushing of the whole head including the base of the skull.

Craniotomy (skull perforation) is an operation to make a perforation of the fetal head to

evacuate the contents followed by extraction of the fetus.
Indications

Hydrocephalus even in living fetus

Dead fetus in obstructed labour with a cephalic presentation

Retained after-coming head of a dead fetus in breech delivery

Cephalopelvic disproportion with a dead fetus

Impacted malpresented dead foetus as mento-posterior and brow presentation

Interlocking head of twins

Contraindication

Live fetus: caesarean section is the choice

Major degrees placenta previa
Pelvic tumour obstructing labour
Gross pelvic contractions

Suspected uterine rupture

Free floating fetal head

Instruments for craniotomy

1.
2.
3.
4.
5.
6.

Catheter
Perforator (old ham)
Budins double channel catheter
Cranioclast
Bone nibbing forceps
Crotchet

Criteria for craniotomy

1. The cervix must be fully dilated
2. The fetus must be dead (hydrocephalus being excluded)
3. Consent should be taken
Sites of Perforation

Vertex presentation: The anterior fontanelle or in the parietal bone as near as to it.

After - coming head:

o The roof of the mouth.
o The foramen magnum.
o The occipital bone behind the mastoid.
o Through the spina bifida if present by a stiff catheter passed up to the spinal canal.

Face: The orbit.

Brow: The frontal bone.

Procedure
Perforation

Under general anaesthesia the bladder is evacuated and head is steadied by an assistant.

The Simpsons perforator is held closed in the operators hand while its tip is protected by
the fingers of the other hand which guide it through the birth canal up to the site of
perforation and applied perpendicular to it.

The tip is forced into the site of perforation up to shoulders of the perforator which is
then opened to produce a linear incision in the skull bones.

The perforator is closed, rotated 90o and re-opened again thus producing a cruciate
incision. The resultant hole is enlarged by the closed perforator which is pushed to allow
drainage of the CSF and brain matter.

The closed perforator is withdrawn while its tip is protected by the fingers.

Alternative methods:
o Needle aspiration vaginally: through the fontanelle or suture line after steadying
the head with Jacobs tenaculum.
o Trans - abdominal aspiration with a syringe or spinal needle.

Extraction

Spontaneous delivery can occur after reduction of the size of hydrocephalus.

Two volsella or Willets scalp forceps may be applied for traction.

Forceps can be applied if there is no disproportion.

The cranioclast (2 blades) or the combined cranioclast and cephalotribe (3 blades) are
used to crush and extract the head if there is disproportion.

The after - coming head is delivered as in breech delivery.

The birth canal should be explored after delivery.

Complications:

1.
2.
3.
4.
5.

Rupture uterus
Injury to cervix, bladder, vagina, rectum, sacral promontory and pelvic floor
Traumatic PPH
Shock
Sepsis

2. DECAPITATION
Definition
It is severing of the fetal head from the trunk for impacted shoulder presentation when the baby
was dead, the mother potentially infected and lower segment thinned out.
Indication

Neglected shoulder with a dead foetus.

Interlocking head of twins.

Double -headed monsters.

Instrument for decapitation

1.
2.
3.
4.
5.
6.
7.

Catheter
Decapitation hook and knife
Embryotomy scissors
Bone ribbing forceps
Crotchet
Obstetric forceps
Cranioclast

Procedure

Under general anaesthesia, the prolapsed arm is grasped to bring the neck within easier
access.

The decapitation hook, protected by the palm of the left hand, is passed up over the
childs shoulder and turned over the neck.

If the hook is sharp, the neck is severed by sawing movement and if it is blunt, rotate it to
cause fracture dislocation of the cervical spines then the soft tissue is cut by an
embryotomy scissors with a blunt tip.

The trunk is delivered first by traction on the arm.

The head is then delivered by hooking a finger into the mouth or with a forceps.

Explore the birth canal.

3. CLEIDOTOMY
Definition
It is division of one or both clavicles with an embryotomy scissors or straight scissors introduced
under the guidance of left two fingers placed inside the vagina to reduce the biacromial diameter
in shoulder dystocia with a dead fetus.
Indication
Dead fetus in shoulder dystocia
Procedure
One hand is placed vaginally along the ventral aspect of the fetus and under this protection a
Kocher clamp can be introduced anteriorly to the clavicle and pulled back against the clavicle to
fracture it. Alternatively, if the fetus is dead, strong straight embryotomy scissors or mayos
scissors can be introduced to cut the clavicle. It is best to cut the skin over the clavicle first and
push the scissors round the bone.
4. EVISCERATION
Definition
It is incision of the abdomen and/ or thorax to evacuate its viscera so reducing its size and
allowing its vaginal delivery.
Indications

Foetal ascitis

Neglected shoulder presentation with dead fetus

Thoracic or abdominal tumours.

Procedure

Under general anaesthesia, a large incision is made in the foetal abdomen with an embryotomy
scissors

then

the

viscera

are

evacuated

manually.

If the thorax has to be incised first the abdominal viscera can be reached via the diaphragm.
5. SPONDYLOTOMY
Definition
It is division of the vertebral column.
Indications

Transverse impaction of a dead foetus when the neck cannot be reached.

In addition to evisceration when the foetus is large or pelvis is deformed.

Procedure
The vertebral column is divided by an embryotomy scissors. The foetus is delivered in 2 halves
by traction on one arm to deliver a half and on a leg to deliver the other.

Management of woman before destructive operation (from book)